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Health insurance terms


A

Affordable Care Act
Also known as Obamacare or the health care law, it’s short for the Patient Protection and Affordable Care Act which was signed into law in 2010 under the leadership of President Barack Obama. Its goal is to make health care more affordable and accessible for millions of Americans. Learn more about the Affordable Care Act.
Annual enrollment period
Also known as the Open Enrollment period, it is the specific time each year that you can buy a health insurance plan, renew the plan you already have, or switch to another plan.
Appeal
When patients ask health insurers to reconsider a decision, such as to not pay a claim.

B

Brand-name drugs
A brand-name drug is a patented, FDA-approved drug. It is usually produced by a single manufacturer with a product name under which the drug is advertised and sold. Newer drugs are usually only available as brand-name drugs. After the original patent expires, a brand-name drug may have a generic equivalent.

C

Chronic conditions
Ongoing medical conditions, such as asthma or diabetes.
Claim
A request for payment that you or your health care provider submits to your health insurer when you receive care. Insurance claims are reviewed by your health insurer to make sure they are for covered services. If so, payment will be made in accordance with the terms and conditions of your health insurance plan.
Coinsurance
The percentage you pay for some covered medical services. If your coinsurance is 20 percent, your health insurance company will pay 80 percent of the cost of covered services; you will pay the remaining 20 percent. The amount you pay is typically not based on the full price of the service. It is based on a discounted rate negotiated by your insurance company.
Copay
Short for copayment, it’s a flat fee you pay when you see a doctor or receive other medical services. For example, a copayment could be $20 to see a doctor or $100 to go to the emergency room.
Cost-sharing
Also known as out-of-pocket costs, it’s the amount of money you pay for a health care service, in the form of copays, deductibles, and coinsurance . This is in addition to the premium or monthly rate you pay to be a member of the health plan.

D

Deductible
The amount you pay each year before your health plan starts paying for services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for the health care services you receive. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs, depending on the plan.
Dental insurance
A type of insurance to help offset the cost of oral care, including routine dental check-ups, cleanings, X-rays, and even orthodontia, depending on the plan. Sometimes your medical plan may include dental coverage, and sometimes you may need to purchase a standalone plan. Independence offers several types of dental insurance in PA.
Direct POS
A Direct Point-of-Service (DPOS) plan allows access to any doctor or hospital, both in and out of network. Members pay less when they choose doctors and hospitals in the network, and more for out-of-network doctors and hospitals.
Durable medical equipment
Durable medical equipment includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies. You should always check with both your provider and health plan to determine whether an item is considered to be durable medical equipment.

E

EPO
An Exclusive Provider Organization plan only covers services from in-network providers, however emergency care by out-of-network providers will also be covered.
Essential Health Benefits
A list of benefits that all individual and small group plans must provide under the health care law. This includes many basic services, such as doctor visits and hospital stays. Benefits will also include preventive care, maternity care, and mental health services.

F

Financial assistance
Also called a subsidy, financial assistance is offered by the federal government to help offset the costs of individual and family health insurance plans. Depending on family size and household income levels, some people may be eligible for a lower premium, lower cost-sharing, or both. See if you qualify for a subsidy.
Flexible Spending Account (FSA)
This is a tax-advantaged account that allows you to pay for qualified medical expenses not covered by your plan, such as copays, deductibles, coinsurance and certain services. An FSA is typically funded by you, as an employee (but your employer can fund as well), and does not need to be paired with a health plan. Any unused funds left over at the end of the year are returned to your employer.
Formulary
A list of prescription drugs that have been selected for their medical effectiveness, positive results, and value. You save the most money with your health plan by choosing drugs on the formulary, even more so if they are generic drugs.

G

Generic drugs
Generic drugs have the same active ingredients as their brand-name drug counterparts. They usually cost less than brand-name drugs and are considered by the U.S. Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. For individuals who must take several medications regularly, generic drugs offer the advantage of being an affordable alternative to brand-name drugs.
Group health insurance
Health insurance you receive through your employer. Typically, your employer shares some of the costs with you.

H

Health Care Law
Also known as the Affordable Care Act, the Patient Protection and Affordable Care Act, or Obamacare, it refers to the law enacted in 2010 under the leadership of President Barack Obama. Its goal is to make health care more affordable and accessible for millions of Americans. Learn more about the Affordable Care Act.
Health Insurance Marketplace
A website where you can compare and buy health plans from various health insurers. Some states, such as Pennsylvania, have their own Marketplace, and others let the federal government operate their Marketplace. See Pennie.com below for information about Pennsylvania’s Insurance Exchange.
Health Reimbursement Accounts (HRAs)
This is a tax-advantaged account that is typically paired with a high-deductible health plan to help you pay for qualified medical expenses not covered by your plan. Because an HRA account is owned and funded by an employer, it does not go with you if you change plans or jobs.
Health Savings Accounts (HSAs)
A health savings account helps you save money for health expenses, tax-free. You don’t pay taxes on the money you put in, the money you take out if it is used for qualified expenses, or any money you earn on the account. HSAs must be paired with a high-deductible health plan that meets the IRS guidelines. The IRS also determines what qualifies as a qualified medical expense, which includes your out-of-pocket costs (copays, deductibles, coinsurance) along with some services not covered by a health plan, such as LASIK surgery. You own your HSA account, so if you change plans or jobs, the account goes with you.
High-deductible health plan
A health plan that has a high minimum deductible that a member must reach before the health plan begins to pay for covered services. HRAs and HSAs may be paired with these plans to help offset the costs of the high deductible. These plans typically offer a lower monthly premium and give members more control over their health care dollars. Also seen as HDHP.
HMO
HMO stands for health maintenance organization. An HMO is a type of health plan that requires you to select a family doctor, often called a primary care physician or PCP. You need a referral from your PCP to see a specialist in the HMO network, such as a cardiologist (heart doctor). Typically, only emergency services are covered if you go outside the HMO’s network of participating providers.

I

In-network providers
The doctors, hospitals, labs, and other health care providers who contract with a health insurance company to deliver services to members. They usually charge discounted rates for their services, so you’ll save the most money by visiting in-network providers.
Individual and family health insurance
If you don’t have the option of buying health insurance through your employer, you can purchase an individual and family health insurance plan directly from a health insurance company, like Independence Blue Cross.
International health plans
A type of insurance to help offset the cost of medical care when travelling or living abroad. Get more information on international health plans.

M

Mail-order
Depending on the health plan you select, you may be able to have medications you take regularly delivered by mail for free. In most plans, you’ll pay less for a 90-day supply when you use mail order/home delivery.
Member
When we use the term “member,” we’re referring to a person who has health care coverage. Members typically receive access to a network of providers, coverage for certain health services, and often tools and wellness programs.
Metallic levels
To make it easier to compare plans, the federal government created four levels of coverage: platinum, gold, silver, and bronze. Platinum health plans have the highest premiums, but have the lowest costs each time you receive care. Bronze health plans have the lowest premiums, but have the highest costs each time you receive care. Gold and silver plans offer more of a balance. There is a fifth level of coverage called “catastrophic,” but this type of plan is only available to individuals under the age of 30 or with an extreme financial hardship.
Monthly rate
Also known as a premium, it’s the set dollar amount you pay each month for your health insurance.

N

network
A provider network is a list of the doctors, other health care providers, and hospitals that a plan contracts with to provide medical care to its members. These providers are called network providers or in-network providers. A provider that isn’t contracted with the plan is called an out-of-network provider.

O

Open Enrollment period
Also known as annual enrollment period, the specific time each year that you can buy a health insurance plan, renew the plan you already have, or switch to another plan.
Out-of-network providers
The doctors, hospitals, labs, and other health care providers who DO NOT have a contract with a health insurance company. Some health plans include coverage (at a higher cost) for out-of-network providers, and some may not provide coverage at all.
Out-of-pocket costs
Also known as cost-sharing, it’s the amount of money you pay for care, in the form of copays, deductibles, and coinsurance. This is in addition to the premium or monthly rate you pay to be a member of the health plan.
Out-of-pocket maximum
This is the maximum amount that you will have to pay for care during the plan year. This does not include your premium, just out-of-pocket costs, such as copays, deductibles, and coinsurance. Any care you receive after you meet your out-of-pocket maximum is covered 100 percent. For example, if your out-of-pocket maximum is $6,000 and you reach this amount, your health plan will cover any additional costs for covered services in full (some exclusions may apply; see your benefits for details).

P

Pennie.com
The Pennsylvania Insurance Exchange (PennieTM) is Pennsylvania’s state-based exchange and has replaced healthcare.gov for Pennsylvanians.
POS
A Point-of-Service (POS) plan offers access to doctors and hospitals in a network. For the highest level of benefits, a primary care physician can refer in-network specialists.
PPO
PPO stands for preferred provider organization. A PPO is a type of health plan that allows members to see providers in and out of the network. You pay lower costs when you see network providers. But you can go outside the network and pay more for your services.
Precertification
This may also be called preapproval or pre-authorization.It means you may need extra approval from your health plan before you receive certain tests, procedures, or medications. It’s a way to make sure the services you’re getting are safe and effective.
Preexisting condition
Any condition, illness, or injury for which medical advice or treatment was recommended or received before a person obtains health insurance. Examples include diabetes, heart disease, and cancer. As part of the ACA, no one can be denied health insurance due to a preexisting condition.
Premium
Sometimes called a monthly rate, it’s the set dollar amount you pay each month for health insurance.
Preventive care
Services that are intended to help you stay healthy and may also detect some diseases in the early stages. Examples include flu shots, mammograms, colonoscopies, and cholesterol tests.
Primary care doctor
Also referred to as a primary care physician, or PCP, this is just another term for your family doctor, or the doctor you see for most of your health care needs. A primary care physician focuses on preventive care and the treatment of routine injuries and illnesses, and may recommend a specialist as needed.
Primary care physician
Often abbreviated to PCP, this is just another term for your family doctor, or the doctor you see for most of your health care needs. A primary care physician focuses on preventive care and the treatment of routine injuries and illnesses, and may recommend a specialist as needed.
Provider
Health care professionals and facilities, such as doctors and hospitals.

Q

Qualifying life event
A change in circumstance that may allow you to enroll in coverage outside of the annual open enrollment period, such as getting married or losing coverage through an employer. Often abbreviated to QLE.

R

Referral
If you have an HMO plan, your primary care physician (PCP) will need to write you a referral before you see other network providers, such as a dermatologist or a cardiologist.
Retail clinic
A retail clinic is a space within a pharmacy or other retail store that is staffed by nurse practitioners. You can use these clinics when your doctor is not available and your injury or illness is minor, such as a sore throat, earache, or skin rash. Care at a retail clinic will cost you less than the same care in a hospital emergency room.

S

Special Enrollment period
Often abbreviated to SEP, this is a period of time outside of the Open Enrollment period in which you may be eligible to apply for an individual and family health plan. If you experience a qualifying life event, such as getting married, having or adopting a baby, losing your coverage, or moving into a new service area, you may qualify for SEP. Learn more about the special enrollment period.
Specialist
A specialist is a physician who provides care for certain conditions in addition to the treatment provided by your primary care physician (PCP). For example, you may need to see an allergist for allergies or an orthopedic surgeon for a knee injury.
Specialty services
These are sometimes referred to as ancillary services, and examples include prescription drug, vision, dental, and life and disability insurance.
Subsidy
Financial assistance offered by the federal government to help offset the costs of individual and family health insurance plans. Depending on family size and household income levels, some people may be eligible for a lower premium, lower cost-sharing, or both. See if you qualify for a subsidy.
Summary of Benefits and Coverage
The federal government requires all health plans to use a standard template to describe the benefits, cost-sharing, and coverage limitations and exceptions included in the plan. Often abbreviated to SBC.

T

Tax credit
A tax credit can be used to lower your premium – the amount you pay each month to your insurance plan. Your tax credit is based on the income estimate and household information you put on the application for health insurance. Find out if you qualify for a tax credit.
Telemedicine
Also called virtual care, telemedicine is a secure, online consultation with a healthcare professional.
Tiered network plan
A tiered network plan divides a provider network into groups called “tiers,” based on cost, and in many cases, quality measures. You can visit doctors and hospitals from any of the tiers, but you’ll save the most on your out-of-pocket costs if you stay within a particular tier. For example, Tier 1 may offer the lowest out-of-pockets costs, Tier 2 may be a bit higher, and Tier 3 may have the highest out-of-pocket costs. These tiers give you an option to save when you choose to see certain health care providers that offer more cost-effective care.

U

Urgent care center
A stand-alone clinic where board-certified doctors treat illness or injury requiring immediate medical attention. You can use these centers when your doctor is not available and your illness or injury is not life threatening, but requires immediate attention, such as a cut requiring stitches or a sprain. Care in an urgent care center will cost you less than the same care in a hospital emergency room. For conditions that are life threatening, such as severe shortness of breath or chest pain, sudden or unexplained loss of consciousness, severe abdominal pain, or a cut or wound that won’t stop bleeding, seek the care of the closest emergency room.

V

Virtual care
Also called telemedicine, virtual care is a secure, online consultation with a healthcare professional.
Vision insurance
A type of insurance to help offset the cost of eye care, such as routine eye check-ups, glass, and contacts. Sometimes vision coverage is included with your medical plan, and sometimes you may need to purchase a standalone plan. Learn more about Independence Blue Cross PA vision insurance.